Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications

Hypertensive Disorders of Pregnancy

• Definition: Hypertensive disorders include any elevated blood pressure condition occurring during pregnancy and are noted as the most common medical condition in pregnant women, affecting approximately up to 15% of all pregnancies.

• Impact: These disorders are associated with significantly higher rates of maternal, fetal, and infant mortality as well as severe morbidity.

• Categories: Hypertensive disorders of pregnancy include several classifications which will be explored in subsequent sections.

Classification of Hypertension in Pregnancy

1. Chronic Hypertension

   • Defined as hypertension present before pregnancy or diagnosed before 20 weeks of gestation.

2. Gestational Hypertension

   • Defined as the onset of hypertension without proteinuria occurring after the 20th week of pregnancy in a woman who previously had normal blood pressure.

3. Preeclampsia/Eclampsia and HELLP

   • Preeclampsia is characterized by hypertension and proteinuria developing after 20 weeks of gestation. Eclampsia involves seizure activity.

4. Chronic Hypertension with Superimposed Preeclampsia

   • Refers to patients with chronic hypertension who develop preeclampsia or eclampsia.

Chronic Hypertension

• Characteristics:

  • Present before pregnancy or diagnosed by week 20 of gestation.

  • It significantly increases the risk of complications for both mother and fetus, including:

    • Abruptio placentae: Premature separation of the placenta from the uterus.

    • Superimposed Preeclampsia: Increased likelihood of developing preeclampsia.

    • Perinatal Mortality: Increased risk for the baby.

    • Fetal Growth Restriction: Stunted development of the fetus leading to smaller size compared to gestational age.

    • Small for Gestational Age: Babies born smaller than the standard for their gestational age.

• Management: Ideally, management begins before conception, possibly requiring lifestyle changes. During the postpartum period, high-risk women must be closely monitored for complications. Women can safely breastfeed despite low levels of antihypertensive medications appearing in breast milk.

Gestational Hypertension

• Definition: Characterized by elevated blood pressure (systolic BP > 140 mm Hg or diastolic BP > 90 mm Hg) occurring after 20 weeks of gestation in women with normal blood pressure prior to this period.

• Diagnosis Criteria: Required diagnosis based on two measurements indicating elevated blood pressure within a one-week period.

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Preeclampsia

• Definition: A pregnancy-specific syndrome where hypertension develops after 20 weeks of gestation in previously normotensive women. It is marked by:

  • Hypertension and the presence of proteinuria.

  • Complicates 1% to 2% of all pregnancies.

Etiology of Preeclampsia

• This disorder is identified as a multisystem, vasopressive disorder for which the etiology is not yet fully understood.

• Risk Factors:

  • Primigravidity: First time pregnancy.

  • Multifetal pregnancy: Carrying more than one fetus.

  • Obesity: Excess body weight.

  • Preexisting Medical Conditions: Such as hypertension or diabetes.

  • History of preeclampsia in prior pregnancies.

Pathophysiology

• Preeclampsia may be caused by:

  • Disruptions in placental perfusion and endothelial cell dysfunction.

  • The primary pathogenic factor is not merely the increase in blood pressure but rather poor perfusion resulting from vasospasm, which narrows blood vessels, impeding blood flow and increasing blood pressure.

• This results in significant compromises in function of key organs, including the placenta, kidneys, liver, and brain.

Management of Preeclampsia

• Vital Signs Management: Monitoring fetal movement and scheduling periodic fetal evaluations via nonstress tests,

• Monitoring: Requires the evaluation of any changes in the woman's condition and regular laboratory result reviews.

Care Management for Mild Gestational Hypertension and Mild Preeclampsia

• The goal here is to ensure maternal safety and deliver a healthy newborn, often managed at home with the following assessments:

  • Daily blood pressure monitoring (every 4-6 hours).

  • Fetal movement counts, engaging in non-stress tests if necessary.

  • Daily weight gain monitoring and urine tests (including dipstick tests).

  • Activity restrictions (bed rest) recommended due to safety considerations.

  • A balanced diet is implemented without sodium restriction and adequate hydration is encouraged.

  • Hospitalization may be warranted in certain situations.

  • Administering IV magnesium sulfate during labor if complications arise.

Teaching Guidelines for Preeclampsia without Severe Features

• Environmental consideration: Encouragement to rest in a quiet environment to avoid cerebral disturbances.

• Hydration: Drinking eight to ten glasses of water daily.

• Diet: High protein and high fiber balanced diet are advised.

• Self-monitoring: Includes:

  • Two blood pressure measurements daily.

  • Recording daily fetal movements.

• Contact medical professional if any of the following occurs:

  • Increase in blood pressure; urinary burning or frequency; decreased fetal activity; severe headaches; dizziness or visual disturbances; stomach pain or excessive heartburn; decreased urination; contractions or back pain.

Care Management for Severe Gestational Hypertension and Severe Preeclampsia

• Defined as blood pressure readings exceeding 160/110 mmHg.

• Hospitalization is essential for continuous monitoring for at least 24 hours, focusing on:

  • Management of blood pressure.

  • Administering magnesium sulfate to prevent seizures and ensuring a quiet environment to avoid stress which could lead to complications.

Preeclampsia with Severe Features

• Requires hospitalization and bed rest typically in the left lateral position to manage risks effectively.

• Environmental adjustments include ensuring a dark, quiet room and potential use of sedatives to encourage rest and reduce seizures.

• Injury Prevention: Important precautions to guard against falls or injury during seizures, including appropriate padding in the room and easily accessible medical equipment.

• Continuous monitoring of blood pressure and administering antihypertensives as necessary.

• Assess and monitor the woman’s vision, level of consciousness, deep tendon reflexes (DTR), and lung sounds as indicators of complications.

Eclampsia Classification

• Defined as seizure activity or coma in women diagnosed with preeclampsia, without any prior seizure disorder history.

• Typical presentation is divided as follows:

  • One third during labor, one third during delivery, and one third within 72 hours postpartum.

Care Management for Eclampsia

• Pre-seizure Signs: Includes:

  • Headache, blurred vision, severe epigastric pain, altered mental status, and hypertension.

• Immediate care post-seizure:

  • Maintaining a patent airway and administering oxygen.

  • Patient safety is paramount, including decisions concerning timing and method of birth post-seizure.

  • Monitor uterine contractions and fetal status throughout the management.

Comparison Chart of Preeclampsia Versus Eclampsia

HELLP Syndrome

• Definition: A severe variant of preeclampsia/eclampsia marked by:

  • Hemolysis (H): RBCs fragment passing through damaged vessels.

  • Elevated liver enzymes (EL): Due to reduced perfusion.

  • Low platelets (LP): Caused by vascular damage and platelet aggregation.

• It's a life-threatening obstetric condition associated with significant risks including pulmonary edema, acute renal failure, DIC, and even maternal death.

Therapeutic Measures for HELLP Syndrome

• Similar management to severe preeclampsia:

  • Stabilizing blood pressure, evaluation of fetal well-being, and magnesium sulfate therapy to prevent seizures.

  • Correcting coagulopathies, infusion of blood products, and potentially administering corticosteroids to induce fetal lung maturity are also part of the management.

Nursing Assessment for Hypertensive Disorders

• Assessment of Risk Factors: Physical exam and thorough laboratory testing including monitoring for protein levels utilizing dipstick tests and/or 24-hour urine collection (gold standard is >300 mg/24hrs).

• Evaluation of nutritional intake, weight consistency, and checks for edema and DTR to assess possible complications.

Medications Used in Preeclampsia and Eclampsia

Key Points on Magnesium Sulfate

• Used primarily in severe preeclampsia to prevent eclampsia, acting as a neuromuscular blocker.

• Dosing Protocol: Initiated with a loading dose of 4-6 g over 15-30 minutes, followed by a maintenance infusion at 2 g/hour.

• Toxicity Levels: Signs of magnesium toxicity occur when levels exceed 8 mEq/L; antidote is calcium gluconate.

• Symptoms: Includes hyporeflexia, respiratory depression, decreased urinary output, hypotension, CNS depression, and potential cardiac arrest.

Assessing Neurological Reflexes

Grading Deep Tendon Reflexes (DTRs)

Assessing the Patellar Reflex

• Procedures for evaluating nervous system irritability related to preeclampsia include checking the patellar reflex using a reflex hammer while assessing movement.

Nursing Implications and Monitoring for Magnesium Administration

• Close monitoring of level of consciousness, vital signs, O2 saturation, and urine output.

• Awareness of signs of magnesium sulfate toxicity and notifying the physician of any significant changes.

• Ensure calcium gluconate is available as an antidote for potential magnesium toxicity.